Renal replacement therapy
From IDWiki
- Decision based on patient symptoms and biochemistry
- Often reserved for GFR < 15
- Goal is to avoid crash starts
- Early referral to nephrologist, pre-dialysis education
- Selection of RRT modality, establishment of access
- Higher morbidity, mortality with emergency start
Hemodialysis
Transplant
- Allograft kidney from one person into another
- Patient must be well enough to undergo surgery, must have iliac arteries and such to attach kidney to
- Candidacy
- ESRD or approaching ESRD
- Cause of CKD doesn't matter
- Pre-transplant assessment
- Risks of procedure
- Risks of comorbidiities
- Risks of suppression
- Risks of rejection
- Pretransplant assessment is extensive
- CBC, electrolytes, liver, INR/PTT
- PTH
- Glucose tolerance test
- ABO group
- Serology for CMV, EBV, VZV, HBV, HCV, HIV; not absolute contraindications
- Possibly serology for Schistosomaiasis
- Tuberculin skin test (TBST)
- CXR
- Abdominal ultrasound
- Iliac Dopplers
- ECG
- Echocardiogram
- Cardiac stress test with imaging
- Age-appropriate cancer screening
- PRA +/- crossmatch
- Consult with: transplant coordinator, nephrologist, surgeon, anaesthesia, social worker
- Consulter:
- Carotid Dopplers
- CT iliacs
- PFTs
Types of donors
- Deceased
- Neurologically deceased
- Donation after cardiac death
- Living donors
- Living-related
- Living-unrelated/emotionally-related
- Altruistic
- Outcomes are better with living donation
- Waiting time is 6-8 years in GTA
Rejection
- Hyperacute
- Zero risk of this with negative crossmatch
- Most common is T-cell mediated acute cellular rejection
- Also B-cell mediated acute antibody-mediated rejection
- Chronic rejection, usually antibody-mediated
Immunosuppression
- Induction with thymoglobulin or basiliximab
- Tacrolimus or cyclosporine
- Mycophenolate (or azathioprine as second-line)
- Prednisone (forever or tapered)
Complications
- Graft dysfunction
- Need for longterm immunosuppression
- Causes HTN, DLD
- Increased risk of infection
- Bone disease
- Recurrence of original kidney disease
- Graft dysfunction
- r/o infection like UTI
- r/o obstruction
- Medication-related problems
